What are the current cervical cancer screening recommendations for average‑risk women, including start age, screening intervals (primary human papillomavirus testing, co‑testing, or cytology alone), stopping age, and special considerations for high‑risk groups, hysterectomy, and pregnancy?

Cervical Cancer Screening Guidelines

Primary Recommendation for Average-Risk Individuals

Begin cervical cancer screening at age 25 years with primary HPV testing every 5 years through age 65 years as the preferred strategy; if primary HPV testing is unavailable, use cotesting every 5 years or cytology alone every 3 years as acceptable alternatives. 1

Age-Specific Screening Protocols

Ages Under 21 Years

• Do not screen regardless of sexual history, age of sexual debut, or other risk factors 1

Ages 21-24 Years (Transitional Period)

• Cytology alone every 3 years is recommended 1, 2
• Do not use HPV testing (either standalone or as cotesting) in this age group 1, 2
• This recommendation reflects the high prevalence of transient HPV infections and low cervical cancer incidence (only 0.8% of all cases) in women aged 20-24 years 1
• Screening before age 25 increases risk of adverse obstetric outcomes from unnecessary treatment of lesions that would spontaneously regress 1

Ages 25-65 Years (Primary Screening Period)

Preferred Strategy:

• Primary HPV testing every 5 years 1, 3, 4

Acceptable Alternatives (transitional only):

• Cotesting (HPV + cytology) every 5 years 1, 3
• Cytology alone every 3 years 1, 3

The American Cancer Society explicitly states that cotesting and cytology-alone options will be phased out and not included in future guidelines as the U.S. completes transition to primary HPV testing 1, 2, 4

Ages Over 65 Years

• Discontinue all screening if adequate prior negative screening is documented 1

Criteria for Stopping Screening at Age 65

Required documentation (must verify through medical records, not patient self-report): 3

• Either: 3 consecutive negative cytology tests within the past 10 years, with the most recent within 5 years 1
• Or: 2 consecutive negative cotests within the past 10 years, with the most recent within 5 years 1
• Or: 2 consecutive negative primary HPV tests within the past 10 years 2
• And: No history of CIN2 or more severe disease within the past 25 years 1

Once screening is discontinued after age 65, do not resume for any reason, including new sexual partners 1

Critical Exceptions Requiring Modified Screening

These guidelines do not apply to the following high-risk populations:

Immunocompromised Individuals

• HIV-positive individuals require annual screening regardless of age 3
• Organ transplant recipients require annual screening 1, 3
• Individuals on chronic corticosteroid therapy require annual screening 1
• Individuals on chemotherapy require annual screening 1

History of High-Grade Lesions or Cancer

• Continue screening for 20-25 years after treatment of CIN2, CIN3, or adenocarcinoma in situ, even if this extends well past age 65 1, 3, 2
• History of cervical cancer requires indefinite screening as long as in reasonable health 3

In Utero Diethylstilbestrol (DES) Exposure

• Requires continued surveillance due to elevated cancer risk 1, 3

Post-Hysterectomy Status

• Do not screen if cervix was removed AND no history of CIN2+ in past 25 years or cervical cancer ever 1, 2, 4
• Continue screening following standard guidelines if subtotal (supracervical) hysterectomy was performed with cervix retained 1

Screening Intervals: Critical Implementation Points

Never screen more frequently than recommended intervals 4

• Annual screening provides minimal additional benefit while substantially increasing harms from false-positives and unnecessary procedures 4
• More frequent screening increases colposcopy rates, overtreatment, and associated complications including adverse obstetric outcomes 1

HPV Vaccination Status

Screening recommendations are identical regardless of HPV vaccination status 1, 4

• Vaccines do not cover all oncogenic HPV types 4
• Cytology-based screening is less efficient in vaccinated populations, further supporting the transition to primary HPV testing 2

Management of Positive Screening Results

All abnormal results require follow-up according to 2019-2020 ASCCP Risk-Based Management Guidelines 1, 3, 4

Immediate colposcopy indicated for: 4

• HSIL (high-grade squamous intraepithelial lesion)
• HPV-positive HSIL
• HPV-positive ASC-H (atypical squamous cells, cannot exclude HSIL)
• Atypical glandular cells (AGC)

Pregnancy Considerations

• Screening recommendations apply to pregnant individuals with a cervix 1
• Follow standard age-based guidelines; pregnancy does not alter screening intervals or methods 1

Common Pitfalls and How to Avoid Them

Documentation Failures

• Always provide written documentation of whether Pap test was obtained, as patient self-reports are frequently inaccurate 3
• Never discontinue screening based on verbal patient history alone; verify adequate prior screening through medical records review 3

Adherence Concerns

• Longer screening intervals may differentially affect adherence in racial/ethnic minorities and individuals with limited healthcare access 1
• Inadequate screening at younger ages is a major predictor of cervical cancer diagnosis at older ages and late-stage disease 1
• Failure to initiate screening near the recommended starting age reduces screening benefits 1

Disparities in Outcomes

• Cervical cancer burden remains higher in racial/ethnic minorities, rural populations, individuals of lower socioeconomic status, and uninsured individuals 1
• These disparities stem from differential screening participation, follow-up rates, health-seeking behaviors, and access barriers 1

Rationale for Primary HPV Testing as Preferred Strategy

Primary HPV testing demonstrates superior performance characteristics compared to cytology:

• Higher sensitivity for detecting CIN3+ lesions 5, 6
• Earlier disease detection 5
• Higher positive predictive value and positive likelihood ratio than cytology 5
• Provides similar protection at 10 years as cytology provides at 3 years, supporting longer screening intervals 7
• The 10-year cumulative CIN3+ risk following negative HPV test is only 0.31%, comparable to 3-year risk after negative cytology (0.30%) 7

Cotesting detects more disease than HPV testing alone but is not efficient 6

• Cotesting strategies were not efficient in decision analysis modeling 6
• Higher false-positive rates lead to unnecessary colposcopies, especially in younger women 2, 8
• The incremental benefit does not justify the increased harms 1